Healthcare professionals have many tools in their arsenal to support diagnosis, but there are few things more important than taking a thorough and accurate history from the patient. Two of the articles in this month’s issue of Guidelines in Practice make reference to the same aphorism: ‘A careful history will lead to the diagnosis 80% of the time.’ The articles are on completely different topics (joint pain and urinary incontinence), which demonstrates that this maxim is applicable across the medical landscape.

Osteoporosis is often asymptomatic and can remain undiagnosed until a fragility fracture happens. Clinical history can be helpful for recognising those at risk of fragility fracture by identifying common risk factors. Dr David Stephens summarises new recommendations from the updated Scottish Intercollegiate Guidelines Network (SIGN) guideline on the management of osteoporosis and the prevention of fragility fractures. The article includes a table from the SIGN guideline, which details non‑modifiable and modifiable risk factors and co-existing diseases that are associated with fragility fracture and should prompt consideration of fracture-risk assessment.

The patient’s history can also provide clues to help distinguish between differential diagnoses. Dr Michael Sproat considers five possible causes of a change in bowel habit, described through hypothetical patient case studies. Age of onset, clinical presentation, and symptom duration may be useful indicators of one cause or another, be it irritable bowel syndrome, coeliac disease, or microscopic colitis. Dr Sproat also discusses management strategies for each of the different conditions and red flags for referral to gastroenterology.

Dr Louise Warburton shares 10 top tips for diagnosing and managing joint pain in primary care. Dr Warburton highlights the importance of taking a thorough history from the patient, and comments: ‘Since the COVID-19 outbreak and the increasing use of video and telephone assessment, this history-taking is even more important as physical assessment is often impossible.’ Important things to note from the history include how long the pain has been present, how it started, the exact location, if it’s worse at a particular time of day, if the patient has any swelling, and the impact it has on their daily life. The article also provides useful reminders about possible inflammatory causes and osteoarthritis, as well as recommendations on assessing the need for joint replacement surgery from recently published NICE guidance. 

Older man holding wrist

Top tips: joint pain

Dr Louise Warburton

Dr Toni Hazell provides 10 top tips about urinary incontinence, and explains why history taking is an important part of a of urinary incontinence assessment. There are typical presentations for each type of urinary incontinence (stress, urgency, and overflow), so the clinical history can provide clues as to which type the patient has, and therefore how management should be tailored. The article also covers criteria for urgent and non‑urgent referral of patients with urinary symptoms, and what to do if a patient has pain or symptoms relating to previous use of mesh. After reading the article, test your updated knowledge using the multiple-choice questions.

In this month’s View from the ground article Dr Emma Nash writes about the impact of the COVID-19 pandemic on patients’ mental health, highlighting the important, but sometimes subtle, distinction between distress and mental illness: ‘Most of the patients who are struggling due to COVID-19 have a normal reaction, not psychopathology. This is not to say that as doctors we don’t have a role. Recognising normality has always been a key component of general practice, and articulating this, with active listening and a healthy dose of empathy, can go a long way.

I’ll finish with a bit of MGP news. It probably won’t come as a surprise that we have decided to run Guidelines Live as a virtual event, rather than holding a face-to-face event at Olympia London. This means that there will be no interruption to your guidance‑focused learning, and you will be able to experience the virtual conference without leaving the comfort of your home or workplace! The state-of-the-art virtual event platform is built to mirror the live event and give an immersive feeling, similar to what you would experience by attending in person. You will be able to watch sessions, visit exhibition booths, network with colleagues, and interact with exhibitors and speakers. The agenda is included in this issue—don’t forget to book your place at: